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 Praise for Emergency Nursing

“This book will entice future emergency nurses to love emergency nursing. Jeff Solheim’s
passion as a nurse, instructor, and leader in emergency nursing will engage and carry you
through this everlasting specialty nursing career to better take care of yourself, your
patients, and their families.”
–Matthew F. Powers, MS, BSN, RN, MICP, CEN
2015 President
Emergency Nurses Association

“Jeff Solheim and his team of talented contributing authors have brilliantly captured the
past, present, and future of emergency nursing. It is exciting and reassuring to know the
essence of our profession will be preserved in published print. The book portrays the rich-
ness, breadth, and diversity of emergency nursing practice. Reading it is like having a chance
to sit down and soak up the institutional knowledge of some of the most experienced nurses
in our profession.”
–Mary Jagim, MS, RN, CEN, FAEN
Chief Nursing Officer and Director of Clinical Services
Infinite Leap, LLC

“This book is an eloquent and honest account of the profession of emergency nursing, guid-
ing readers throughout the independent and collaborative nature of this specialized practice
into their own journeys to emergency nursing.”
–Sherri-Lynne Almeida, DrPH, MSN, MEd, RN, CEN, FAEN
Senior Consulting Manager, Philips Healthcare
Past President, Emergency Nurses Association (2002)
“Filled with concrete information, skill enhancing tips, professional leadership advancement
practice, and overall career opportunities, this book will answer all your questions and
concerns about a future in emergency nursing. A must-read for students of all levels!”
–Cammy House Fancher, ACNP
University of Florida, Division of Cardiothoracic Surgery
CEO, Critical Care Advanced Medical Institute

“Jeff Solheim has written a useful guide to students contemplating emergency department
nursing as a career. Emergency Nursing explores additional fields available to ED
professionals—including global health nursing services in underdeveloped countries along
with preparation for the emotional and physical challenges of working abroad. Solheim’s
discussion about legacy explores what nurses hope to achieve and how those achievements
contribute to their profession.”
–Judith Harris, DNP, FNP-BC, RN
Assistant Professor
University of New Mexico College of Nursing
Albuquerque, New Mexico

“The perfect emergency nursing guidebook, both pertinent and practical. Definitely the #1
book addressing the past, present, and future issues related to emergency nursing.”
–Gwyn Parris-Atwell, MSN, RN, FNP-BC, CEN, FAEN
New Jersey Emergency Nurses Association Past-President
EMERGENCY
NURSING
The Profession the Pathway the Practice
■ ■

Jeff Solheim, MSN, RN-BC, CEN, CFRN, FAEN

Copyright © 2016 by Sigma Theta Tau International
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ISBN: 9781940446462
EPUB ISBN: 9781940446479
PDF ISBN: 9781940446486
MOBI ISBN: 9781940446493
_______________________________________________________________________________________________________
Library of Congress Cataloging-in-Publication data

Names: Solheim, Jeff, 1967- , editor. | Sigma Theta Tau International,

issuing body.
Title: Emergency nursing : the profession, the pathway, the practice /
[edited by] Jeff Solheim.
Other titles: Emergency nursing (Solheim)
Description: Indianapolis, IN, USA : Sigma Theta Tau International, [2016] |
Includes bibliographical references.
Identifiers: LCCN 2015042809| ISBN 9781940446462 (alk. paper) | ISBN
9781940446479 (epub) | ISBN 9781940446486 (pdf) | ISBN 9781940446493 (Mobi)
Subjects: | MESH: Emergency Nursing. | Emergencies--nursing. | Emergency
Service, Hospital.
Classification: LCC RC86.7 | NLM WY 154.2 | DDC 616.02/5--dc23 LC record available at http://lccn.loc.
gov/2015042809
_______________________________________________________________________________________________________
First Printing, 2016
Publisher: Dustin Sullivan Principal Book Editor: Carla Hall
Acquisitions Editor: Emily Hatch Development and Project Editor: Rebecca Senninger
Editorial Coordinator: Paula Jeffers Copy Editor: Erin Geile
Cover Designer: Rebecca Batchelor Proofreader: Todd Lothery
Interior Design/Page Layout: Rebecca Batchelor Indexer: Joy Dean Lee
Dedication
I want to dedicate this book to my incredible family, who has been so supportive of me and
my career over the years. With each new venture I have taken on, my time has become more
precious. Sadly, that has often meant less time with those I love the most. This written work
is but one testament of the appreciation I have for my entire family and for the support they
have shown me.

To my parents, Dr. Allen Solheim and Dorthy Solheim, thank you for setting the example of
professionalism and hard work that has guided my life and career. You have set the example
that I have followed. It is unlikely I could accomplish everything I currently do without your
support, and you hold a special place in my heart.

To my son, Brandon, I know that my busy life has often meant we are apart more than I
would have liked. But I have watched you grow up with the greatest of pride and admiration
and can’t wait to see where life takes you next. Thanks for being willing to share me with so
many others. I hope the example I have set will be a guiding light for you in life.

To Sue, you were so supportive of me early in my career as I entered into emergency nursing.
I have never forgotten the sacrifices we made as a young family so I could do what I loved.

Aside from my family, there are many other incredible individuals who have shaped my
emergency nursing career. Sandy Broderick, who was a patient and supportive preceptor
when I first entered into the emergency nursing field, thank you for your patience and guid-
ance. And to Jean Belbeck—my first charge nurse who provided a lifeline when I was the
victim of terrible lateral violence in my first emergency department job. I doubt I would have
survived those horrible months if not for your moral support.

It’s important for me to recognize the incredible staff who allow me to pursue all of my pas-
sions in emergency nursing, working behind the scenes to make me look good and allow me
to balance all the facets of my professional and personal life. Special recognition goes to my
personal assistants over the years: Shaun Willis, Doug Peterson, and Thom Larkin. It’s no
small task to keep tabs on my incredibly busy life and to put up with all the demands that
come your way, but you have done so with professionalism and unparalleled patience. And
to Ken Weaver, the amazing director of operations at Project Helping Hands who has self-
lessly taken the reigns of my organization and grown it over the years, thank you for not
only allowing Project Helping Hands to flourish but for freeing up time for me to pursue the
multitude of projects that comprise my life.

And last, but not least, I would be remiss if I did not dedicate this book to the very individu-
als for which it is written, my colleagues in the emergency nursing field. You have dedicated
your life to the selfless care of others. You spend countless holidays away from your own
family. You work hours that few others would work to ensure that patients receive care
around the clock. You put yourself in harm’s way every time to report to work. May this
book serve as inspiration and guidance in recognition of the career path you have chosen.
Acknowledgments
I want to thank all the authors who have been integral in putting this book together. We all
live busy lives these days, and taking time out of a busy schedule to author a chapter consti-
tutes great sacrifice. Thank you for agreeing to take time away from your personal life for
this project, for meeting tight deadlines, and for putting up with all my queries and edits.

Thank you to Emily Hatch at Sigma Theta Tau International for inviting me to take on this
project and for patiently working with my busy schedule to initiate the project. Thank you
to the entire production team (including but not limited to Carla Hall, Dustin Sullivan,
Paula Jeffers, Rebecca Batchelor, Rebecca Senninger, and Erin Geile) at Sigma Theta Tau
International for taking this idea and developing it into a reality.
About the Author
Jeff Solheim, MSN, RN-BC, CEN, CFRN, FAEN, is founder and executive direc-
tor of Project Helping Hands and president of Solheim Enterprises. Solheim is
well known in the emergency nursing field. He has been a nurse since 1989 and
an emergency nurse since 1993. He has worked in nearly every facet of emergen-
cy nursing including staff nurse, charge nurse, manager, director, trauma coordi-
nator, flight nurse, educator, state surveyor, and pre-hospital nurse. Since 2004,
Solheim has been traveling around the world speaking on a variety of clinical and
motivational topics. He has also authored more than 20 books and written sev-
eral chapters for other books as well as being published in numerous journals and
magazines. Aside from Solheim’s work in the emergency nursing field, he is
founder and executive director of Project Helping Hands, a Third World humani-
tarian medical organization that places short-term medical teams in countries
around the world. He has personally led more than 50 different medical teams to
countries in all but one continent.
Contributing Authors
Pamela D. Bartley, BSN, RN, CEN, CPEN, CCRN, is president of PDB Nurse Education
LLC and has more than 30 years’ experience as an emergency nurse and educator, teaching
courses as diverse as Basic Life Support, Advanced Cardiac Life Support, Pediatric
Advanced Life Support, Trauma Nursing Core Curriculum, and the Emergency Nurse Pedi-
atric Course, as well as preparation courses for the Certified Emergency Nurse and Certi-
fied Pediatric Emergency Nurse exams. Bartley has served on the South Carolina LLR
Nursing Advisory Board and as an NCLEX item reviewer. She was selected for the AACN
Wyeth Nurse Fellow Award in May 2002 and published “The Evolution of ACLS” in the
American Journal of Nursing. She was elected as the South Carolina Emergency Nurses
Association’s president in 2001 and in 2013. In 2014, Bartley was honored as the South
Carolina Area Health Education Center Educator of the Year and was selected for the
2014 ENA Board Mentoring Program and the Academy of Emergency Nursing’s EMI-
NENCE Mentoring Program. She currently serves on the ENA State Achievement Award
Committee.

Patricia L. Clutter, MEd, RN, CEN, FAEN, is an ED staff nurse, an independent educator,
a journalist, and a ship nurse. She has spent 41 years of her 43-year career in emergency
nursing. Clutter has lectured nationwide on a variety of topics, including the Certified
Emergency Nurse review course, cultural aspects of care, and triage, and has presented
internationally. She has written numerous articles, chapters, and books related to patient
care and serves as co-section editor for international nursing in the Journal of Emergency
Nursing. Clutter was director of education for more than 10 years for a Third World
humanitarian medical mission group, Project Helping Hands, and is presently regional edu-
cation director for South America with this organization. She also has been a team member
on multiple medical mission trips to Bolivia. Clutter continues to work part time as a cruise
ship nurse, which has afforded her many unique patient care situations. She is also active in
the Emergency Nurses Association at the local, state, and national level and was inducted
into the Academy of Emergency Nursing in 2005.

Debra Delaney, MS, RN, CEN, is owner and proprietor of Delaney Healthcare Consul-
tants. She has more than 20 years of experience as an emergency nurse and nursing leader.
Her roles in the ED have ranged from transporter to director. Delaney’s experience also
includes more than 8 years as a consultant, traveling across the United States to help emer-
gency departments with redesign and process-improvement opportunities. Her expertise in
improving throughput and hospital crowding has gained her national recognition, and she
is a sought-after speaker on the topic. She has published several articles and lectures on
strategies to improve emergency care, best practices, and current trends in nursing. Delaney
is a certified emergency nurse and an active member of the Emergency Nurses Association.
She has represented nurses in Massachusetts as a delegate at the ENA General Assembly
 CONTRIBUTING AUTHORS ix

annual nursing conference. Her nursing honors include Sigma Theta Tau International and
Alpha Sigma Lambda. She is also a member of the American College of Healthcare Execu-
tives and the American Organization of Nurse Executives.

Darin L. Durham, BSN, RN, is staff nurse at St. Charles Immediate Care and deputy medi-
cal examiner and law enforcement death investigator for Deschutes County in Oregon. He
has been an emergency nurse since 1998. Durham started as an EMT in 1985 and then
spent 10 years as a medical lab technician before finishing nursing school. He also spent 2
years as an ICU nurse for both adult and pediatric patients with a specialty in trauma. He
has held positions in emergency departments as a staff nurse, trauma nurse, charge nurse,
emergency department manager, and director of emergency and mental health services. Out-
side of the emergency department, Durham volunteers for several organizations. He pro-
vides emergency first aid for school and local sporting events; lectures to high school driv-
er’s education classes; and teaches classes to EMTs, paramedics, nursing students, firefight-
ers, and police officers.

Laurel Grisbach, BSN, RN, CPHRM, is director of risk management and patient safety at
Beta Healthcare Group, where she provides risk and patient-safety consultation and educa-
tion for more than 100 healthcare facilities and medical groups throughout California. She
is a certified professional in healthcare risk management and a registered nurse with exper-
tise in emergency nursing and ED operations. Grisbach completed her patient safety leader-
ship fellowship through the American Hospital Association and serves on the association’s
CPHRM Certification Committee. In addition to her work in the professional liability
arena, she was a legal nurse consultant for civil and criminal cases in local and federal juris-
dictions. Grisbach was an expert witness for emergency nursing, operations, and EMTALA
and served as a facility-based risk manager for a region of hospitals, with responsibilities
for risk management, compliance, privacy, and patient safety. She is a published author and
speaks nationally on topics involving clinical risk management and risk reduction.

Linda Laskowski-Jones, MS, APRN, ACNS-BC, CEN, FAWM, FAAN, vice president of
emergency and trauma services at Christiana Care Health System in Wilmington, Delaware,
is a nationally recognized nurse leader and educator in emergency and trauma care. She has
authored more than 100 journal articles and book chapters. She is editor-in-chief of Nurs-
ing, the Journal of Clinical Excellence, and is an editorial board member for the Interna-
tional Journal of Emergency Nursing. She has served on the editorial boards of the Journal
of Emergency Nursing and the Journal of Trauma Nursing. Laskowski-Jones is a nurse
reviewer for the American College of Surgeons Committee on Trauma Consultation and
Verification Program. She has served as national course faculty for the Emergency Nurses
Association Key Concepts in Emergency Department Management Course. She is a gover-
nor-appointed past president of the Delaware Board of Nursing. She serves on the Dela-
ware Trauma System and Trauma Quality committees. She is a member of the board of
x EMERGENCY NURSING

directors for the Appalachian Center for Wilderness Medicine and a fellow of the Academy
of Wilderness Medicine.

Rebecca S. McNair, RN, CEN, founder and president of Triage First Inc., has a 28-year his-
tory in emergency nursing. For the last 17 years, she has been an educator and consultant
specializing in emergency-department triage and patient-throughput systems, customer satis-
faction, teamwork, and leadership skills. Her company has received accreditation with dis-
tinction as an accredited provider of continuing nursing education. She has been published
in the Journal of Emergency Nursing and Physicians Weekly, addressing triage and point-
of-entry processes as well as a range of clinical topics. She co-authored the triage chapter in
Emergency Nursing Secrets and authored eight chapters in Triage Secrets. Recently, she
authored the foreword and the documentation chapter in Fast Facts for Triage. She was a
member of the ENA/ACEP Joint Triage Task Force regarding the adoption of a valid and
reliable five-level triage acuity scale. She has been a featured faculty member at various pro-
fessional organization conferences, including an Emergency Department Practice Manage-
ment Association meeting.

Fred Neis, MS, RN, CEN, FACHE, FAEN, managing director at The Advisory Board Com-
pany, obtained his BSN in 1993 and an MS in nursing administration in 1997 from the
University of Kansas. He served in a variety of clinical and leadership roles in hospitals and
emergency medical services until joining The Advisory Board Company in 2006. Currently,
Neis leads complex partnerships aimed at transforming care delivery at large health sys-
tems. Additionally, he has been a contributor to several publications, including the Institute
of Medicine (IOM) reports on The Future of Emergency Care in the U.S. Health Sys-
tem (2006) and Strauss and Mayer’s Emergency Department Management (2013). Continu-
ing to participate in emergency nursing, he is a conference speaker and peer reviewer
for Journal of Emergency Nursing, Advanced Emergency Nursing Journal, and Journal of
Healthcare Management. Outside of his role at The Advisory Board Company, he has
served on several medical mission trips to Africa through Project Helping Hands (PHH),
has been president of the PHH board, and volunteers for a fire department.

Nicholas A. Nelson, MS, RN, CEN, CPEN, CCRN, CPN, TNS, NRP, is an ECRN EMS
instructor for emergency medical services and a per diem staff nurse for the emergency
department. In his current role, he coordinates 300 emergency communications RNs at the
eight hospitals of the Loyola EMS System. Besides educating emergency nurses, he instructs
EMT and paramedic students, EMS and critical care transport providers, school nurses, and
graduate nursing students. Nelson is also a pediatric quality coordinator in a suburban
emergency department/Level I Trauma Center, a critical care transport nurse, and a state
surveyor of pediatric EDs. He holds board certifications in emergency nursing, pediatric
emergency nursing, adult acute and critical care nursing, and pediatric nursing. He volun-
teers as event medical personnel and embarked on his first international medical mission
trip in 2015. Aside from nursing, he is a licensed and nationally certified paramedic,
 CONTRIBUTING AUTHORS xi

certified emergency medical dispatcher, and certified child passenger safety technician. Nel-
son is the 2013 recipient of the national Emergency Nurses Association’s Rising Star
Award.

William Schueler, MSN, RN, CEN, an emergency staff nurse and clinical nurse educator,
has been an emergency nurse since 2000. In 1997, he became an EMT, which led to posi-
tions as a transport nurse and travel nurse. Through understanding and research of the per-
vasive problem of violence in healthcare, Schueler has been teaching violence prevention
since 2012. His experience as a weight loss nurse enables him to identify with the stressors
of life and how they holistically affect body weight and health. Schueler has been president
of the Oregon Emergency Nurses Association and has been active in pursuing legislation to
increase penalties for assaults to hospital staff. He continues to be an active martial artist
and advocate for the profession of emergency nursing.

Brian Selig, DNP, RN, CEN, NEA-BC, is assistant director of perioperative and procedural
services at the University of Kansas Hospital in Kansas City, Kansas. He has been a nurse
since 1998 and has worked extensively in emergency nursing throughout his career. He has
held positions as an ER staff RN, flight nurse, and nursing administrator. Selig has been a
leader in several emergency departments, including teaching facilities, ACS Level I Trauma
Centers, and a comprehensive stroke center. He has expertise in emergency nursing at mass
gatherings and has established healthcare operations for teams in Major League Baseball
and NASCAR. Selig has served as a commissioner for the ANCC Commission on Magnet
Recognition since 2009 and is currently serving on the ANCC Magnet Commission Execu-
tive Committee. He was a 2008 AONE Nurse Manager Fellow and was the 2011 Kansas
Emergency Nurses Association president. He is a 2012–2014 National Jonas Scholar.

Renee Semonin Holleran, PhD, FNP-BC, CEN, CCRN (emeritus), CFRN, CTRN (retired),
FAEN, a family nurse practitioner at Alta View Senior Clinic and Hope Free Clinic, began
her career in the ED in 1977 as a staff nurse. Since then, she has worked as an emergency
nursing clinical nurse specialist, a transport nurse, a chief flight nurse, and now a family
nurse practitioner. She has written and edited two AJN “Book of the Year” books: Prehos-
pital Nursing: A Collaborative Approach (1994) and Air and Surface Transport Nursing:
Principles and Practice (2011). She was editor of Air Medical Journal from 1996 to 2006
and editor-in-chief of Journal of Emergency Nursing from 2006 to 2013.

Melanie Stoutenburg, BSN, RN, CEN, clinical educator for emergency services and emer-
gency services nurse residency program coordinator, has been an emergency room nurse
since 1996. Over the years, she has served in numerous roles including staff nurse, charge
nurse, clinical coordinator, and educator. Her most recent role has focused on the develop-
ment and implementation of a nurse residency program that facilitates the transition of the
new graduate nurse into a well-rounded professional emergency department nurse. Stouten-
burg also teaches a variety of educational courses, including preparation courses for the
xii EMERGENCY NURSING

Certified Emergency Nursing Exam. She is an active member of both her local and state
Emergency Nurses Association, serving in the positions of chapter president, state presi-
dent-elect, and past chapter and state secretary.

Christi Thornhill, MSN, RN, ENP, ACNP-BC, CPNP-AC, CEN, CA-SANE, CP-SANE,
has been a nurse since 1990 and a nurse practitioner since 2000. Her nursing career start-
ed in the emergency department, and she has worked as an emergency nurse in urban,
suburban, and rural emergency departments as well as a flight nurse. She worked as an
emergency nurse practitioner in rural emergency departments until 2008, when she
obtained her post-master’s degree as an acute care pediatric nurse practitioner. Thornhill
worked as the lead nurse practitioner in trauma services for 6 years at Cook Children’s
Medical Center in Fort Worth, Texas. In 2014, she transitioned to the Child Advocacy and
Resource Evaluation (C.A.R.E.) team caring for physically and sexually abused children.
She is a certified sexual assault nurse examiner, a certified emergency nurse, and a certified
emergency pediatric nurse. She speaks frequently on topics that include emergency and
trauma care, child abuse, and human trafficking

Gayle Walker-Cillo, MSN/Ed, RN, CEN, CPEN, FAEN, stroke program clinical specialist
at Morristown Medical Center in Morristown, New Jersey, has been an emergency nurse
for more than 20 years, with 15 of those years as a full-time emergency clinical specialist
and bedside educator. She is currently applying her emergency skills in working across the
continuum to improve care of patients who experience strokes. Walker-Cillo has consult-
ed, presented, collaborated, and authored on both state and national levels on topics that
include emergency nursing, education, remediation, competence, and research. She has
been on the editorial board for the Advanced Emergency Nursing Journal, has written and
edited for Gannett and Mosby, and has been published in more than 20 peer-reviewed
journals. In 2009, she was lead author of the sentinel clinical practice guideline (CPG)
process for emergency nurses. She also collaborated on and co-authored Emergency Nurs-
ing Scope and Standards of Practice 2011 and A Framework for Creating and Evaluating
Competencies for Emergency Nurses.

Aaron Wolff, BSN, RN, CEN, director of performance excellence at Dignity Health, is an
accomplished leader in professional nursing. In addition to leadership roles within the hos-
pital, he has lectured across the nation on topics of adult, pediatric, and trauma nursing as
well as nursing and hospital leadership since 2004. He has been a contributing author to
many textbooks while also partnering with some of the most accomplished industry lead-
ers to develop nursing education programs for trauma. While his interest for hospital
operations and business performance improvement was born in the emergency depart-
ment, his focus has expanded to include all aspects of clinical and operational efficiency in
both acute and outpatient settings. Since 2008, Wolff has used tools such as LEAN, Six
Sigma, and human-based design, and his passion for engineering outcomes in healthcare,
to express his commitment to professional nursing.
Table of Contents
About the Author . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . vii
Contributing Authors. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . viii
Foreword. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . xviii
Introduction. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . xx

1 Emergency Nursing Defined. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1

Renee Semonin Holleran, PhD, FNP-BC, CEN, CCRN (emeritus), CFRN,
CTRN (retired), FAEN
History of Emergency Nursing. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 2
Role of the Emergency Department . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 10
Emergency Nursing as a Specialty . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 12
Emergency Nursing Competencies . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 15
Summary. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 16
References. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 17

2 The Traditional Role of the Emergency Nurse. . . . . . . . . . . . . . . . . 21

Darin L. Durham, BSN, RN; and Jeff Solheim, MSN, RN-BC, CEN, CFRN, FAEN
Direct Patient-Care Roles . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 22
Administrative Roles. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 30
Other Hospital Roles for Emergency Nurses . . . . . . . . . . . . . . . . . . . . . . . . . . . 36
Summary. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 38
References. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 39

3 Unique Roles of the Emergency Nurse. . . . . . . . . . . . . . . . . . . . . . 41

Patricia L. Clutter, MEd, RN, CEN, FAEN
Entrepreneurship/Intrapreneurship. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 42
Forensic Nursing . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 43
Nursing Jobs With the Federal Government. . . . . . . . . . . . . . . . . . . . . . . . . . . . 46
Cruise Ship Nurse. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 50
Humanitarian Nursing. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 51
Disaster Nursing. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 54
Camp Nursing . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 54
On-Set Nursing. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 55
Finding Other Nursing Options. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 56
Summary. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 57
References. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 57
xiv EMERGENCY NURSING

4 Education of the Emergency Nurse. . . . . . . . . . . . . . . . . . . . . . . . . 59

Nicholas A. Nelson, MS, RN, CEN, CPEN, CCRN, CPN, TNS, NRP
Nursing Education Today. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 59
The Future of Nursing Education. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 60
Accreditation. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 62
Nursing Degree Titles: What’s the Difference?. . . . . . . . . . . . . . . . . . . . . . . . . . 63
Entry Into Practice. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 64
Bridge Programs. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 74
Advanced Nursing Education. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 77
Doctoral Degrees . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 80
APRN Specialty Programs. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 85
Continuing Education. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 90
Summary. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 95
References. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 96

5 The Emergency Nurse as a Professional. . . . . . . . . . . . . . . . . . . . . 99

Linda Laskowski-Jones, MS, APRN, ACNS-BC, CEN, FAWM, FAAN
Fostering Evidence-Based Practice. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 101
Seeking Lifelong Learning/Maintaining Competency. . . . . . . . . . . . . . . . . . . . . 105
Gaining Certification . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 109
Adhering to Institutional Policies and Procedures . . . . . . . . . . . . . . . . . . . . . . 111
Serving on Institutional Committees. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 113
Joining Professional Organizations . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 115
Influencing Legislation . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 119
Volunteering. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 122
Personal Professional Liability Insurance . . . . . . . . . . . . . . . . . . . . . . . . . . . . 125
Promoting Health/Injury Prevention/Community Education . . . . . . . . . . . . . . . 126
Summary. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 130
References. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 130

6 Self-Care and the Emergency Nurse. . . . . . . . . . . . . . . . . . . . . . . 133

William Schueler, MSN, RN, CEN
Emotional Health. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 134
Lateral Violence. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 140
Physical Violence and Aggression. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 142
Spiritual Care. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 146
Physical Health . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 147
Minimizing the Negative Effects of Shift Work. . . . . . . . . . . . . . . . . . . . . . . . . 152
Summary. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 155
References. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 155
 TABLE OF CONTENTS xv

7 Types of Emergency Departments. . . . . . . . . . . . . . . . . . . . . . . . . 161

Aaron Wolff, BSN, RN, CEN
Types of Hospitals. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 161
Specialty Emergency Departments. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 167
Disease Specific Centers, Certifications, and Designations. . . . . . . . . . . . . . . . 172
Summary. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 176
References. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 177

8 Common Areas Within the Emergency Department . . . . . . . . . . . . 179

Debra Delaney, MS, RN, CEN; and Jeff Solheim, MSN, RN-BC, CEN, CFRN, FAEN
Waiting Area (Lobby/Reception Area) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 180
Emergency Department Configuration. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 186
Summary. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 198
References. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 199

9 Key Players in the Emergency Department. . . . . . . . . . . . . . . . . . 201

Pamela D. Bartley, BSN, RN, CEN, CPEN, CCRN; Melanie Stoutenburg, BSN, RN, CEN;
and Jeff Solheim, MSN, RN-BC, CEN, CFRN, FAEN
Medical Care Providers. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 202
Positions Frequently Supervised by the Emergency Nurse . . . . . . . . . . . . . . . . 207
Allied Personnel an Emergency Nurse Frequently Encounters. . . . . . . . . . . . . . 209
Support Services . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 213
Summary. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 214
References. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 214

10 The Emergency Nurse in the Role of Triage . . . . . . . . . . . . . . . . . 217

Rebecca S. McNair, RN, CEN; and Jeff Solheim, MSN, RN-BC, CEN, CFRN, FAEN
Understanding What Triage Is . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 218
Triage Nurse Qualifications . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 219
Triage Systems . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 221
Implementing a Triage System. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 222
The Triage Process . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 224
Advanced Triage Protocols (ATPs). . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 234
Patient Disposition. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 236
Ambulance Triage . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 237
Common Pitfalls in Triage. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 237
Summary. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 240
References. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 240
xvi EMERGENCY NURSING

11 Common Challenges Faced by Emergency Nurses. . . . . . . . . . . . . 243

Brian Selig, DNP, RN, CEN, NEA-BC; Fred Neis, MS, RN, CEN, FACHE, FAEN; and
Jeff Solheim, MSN, RN-BC, CEN, CFRN, FAEN
Violence in the Emergency Department. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 245
Restraints/Seclusion. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 247
Service Excellence and Patient Experience. . . . . . . . . . . . . . . . . . . . . . . . . . . 249
Recidivism (Frequent ED Utilizers). . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 252
Ethics in the ED. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 253
Patient Consent and Refusal of Care . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 256
Patient Throughput. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 258
Boarders in the Emergency Department . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 261
Ambulance Diversion . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 262
Communicable Disease Management. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 264
Disaster Preparedness and Response. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 265
Hospital Emergency Response . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 268
Telephone Advice or Release of Patient Information. . . . . . . . . . . . . . . . . . . . . 268
Family Presence During Resuscitation . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 269
Organ and Tissue Donation . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 270
Impaired Co-Workers. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 273
Social Media . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 274
Summary. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 276
References. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 276

12 Risk Management and Quality Issues Affecting the

Emergency Nurse . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 281
Laurel Grisbach, BSN, RN, CPHRM
Acceptable Standard of Care. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 282
Risk Management. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 283
Negligence, Malpractice, and Litigation . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 285
Standard of Care . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 289
Risk Identification . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 292
Primary Causes of Unexpected Events . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 298
Mitigating Risk. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 309
Implementing Best Practices. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 320
Summary. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 331
References. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 332

13 Emergency Nursing Throughout the Lifespan. . . . . . . . . . . . . . . . . 337

Gayle Walker-Cillo, MSN/Ed, RN, CEN, CPEN, FAEN; Renee Semonin Holleran,
PhD, FNP-BC, CEN, CCRN (emeritus), CFRN, CTRN (retired), FAEN; and
Jeff Solheim, MSN, RN-BC, CEN, CFRN, FAEN
The Pregnant Patient . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 338
The Pediatric Patient . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 342
 TABLE OF CONTENTS xvii

The Older Adult . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 351

Summary. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 357
References. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 357

14 Challenging Patient Populations Encountered by the

Emergency Nurse . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 361
Gayle Walker-Cillo, MSN/Ed, RN, CEN, CPEN, FAEN; Renee Semonin Holleran, PhD,
FNP-BC, CEN, CCRN (emeritus), CFRN, CTRN (retired), FAEN; and
Jeff Solheim, MSN, RN-BC, CEN, CFRN, FAEN
Recidivism. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 362
Patients Experiencing Psychiatric Illnesses. . . . . . . . . . . . . . . . . . . . . . . . . . . 363
The Homeless Patient. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 369
Patients With Altered Mental Status. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 372
Summary. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 380
References. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 380

15 The Emergency Nurse and the Abused Patient . . . . . . . . . . . . . . . 383

Gayle Walker-Cillo, MSN/Ed, RN, CEN, CPEN, FAEN; Renee Semonin Holleran,
PhD, FNP-BC, CEN, CCRN (emeritus), CFRN, CTRN (retired), FAEN; and
Christi Thornhill, MSN, RN, ENP, ACNP-BC, CPNP-AC, CEN, CA-SANE, CP-SANE
Child Abuse. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 384
Domestic Human Trafficking. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 399
Intimate Partner Violence . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 407
Sexual Assault. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 411
Elder Abuse. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 417
Summary. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 421
References. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 421

16 The Emergency Nurse Caring for Diverse Cultures and

Ethnicities . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 425
Patricia L. Clutter, MEd, RN, CEN, FAEN
Whose Viewpoint?. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 426
Major Points to Consider. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 426
Cultural Phenomena. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 431
Summary. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 435
References. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 436

Index . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 437
xviii EMERGENCY NURSING

Foreword
As I was reading through the chapters of this book, I couldn’t help but reminisce about the
beginning of my personal journey as an emergency nurse. As a very young Army nurse, I
was assigned head nurse of the emergency room of a small military hospital in what was
then West Germany. Not only was I the head nurse, I was the only nurse. Our entire ER
team consisted of 10 young Army medics, three foreign physicians—from Turkey, Iran, and
Egypt—and me. The ER was one large room with three stretchers separated by curtains
and a small, one-stretcher room. We had no clinical policies, protocols, or practice guide-
lines to help us. On occasion, I was designated “flight nurse,” accompanying a critically ill
or injured patient to a larger facility about an hour’s flight north. Our aircraft was a
Huey—a noisy, rattly, drafty, but very reliable helicopter, minimally equipped with an O2
E-cylinder, a BP cuff and stethoscope (which were not very useful during flight), and glass
bottles of IV solutions suspended from the ceiling by strips of gauze.

Fast-forward more than four decades and witness the phenomenal growth and development
of emergency nursing as a specialty. The advent of this book, which is a very thorough
archive and compendium of all things emergency nursing, chronicles the history of emer-
gency nursing, its maturation, its complexity, and key components that validate its variety
and uniqueness.

For those of you who are exploring nursing specialties, whether this is your first or last
stop, buckle your seat belts and get ready for a whirlwind ride into the universe of emer-
gency nursing. Extraordinary, visionary, dedicated pioneer nursing leaders identified the
need for designated practice areas, knowledgeable nurses, lifelong learning, a scope and
standards of practice, and a code of ethics unique to the practice of emergency nursing.
This foundational work was the beginning of a journey that continues to this day as emer-
gency nurses work side by side with emergency physicians and emergency medical services
men and women to continuously improve the specialty of emergency care.

To say that this book is carefully detailed and extremely timely would be an understate-
ment. It captures the essence and breadth of emergency nursing. Its chapters offer you an
opportunity to look into the vast universe of emergency nursing, from our rich history to
the present and into the future. You can focus on a particular component of the specialty or
absorb a broad range of topics.
 FOREWORD xix

The three sections of this book logically span the many aspects that make up emergency
nursing, types of emergency care, educational preparation, certifications, and the importance
of the team. It presents the practice of emergency nursing, with its challenges, regulations,
populations, legal aspects, and variety of practice settings. Of particular importance to all
emergency nurses, regardless of the length of time or types of experiences encountered, is the
chapter on self-care. Dealing with births, deaths, and every human condition in between on
any given day is an extreme challenge to one’s life-balance. Self-awareness, self-care, and
attentiveness to fellow emergency nurses form the bonds that help us get through the chal-
lenging times and celebrate the good times.

Led by contemporary visionary and emergency nurse extraordinaire, book editor, and author
Jeff Solheim, the 17 authors are staff nurses, charge nurses, nurse managers, directors, edu-
cators, journalists, administrators, consultants, editors, nurse practitioners, medical examin-
ers, sexual assault nurse examiners, clinical nurse specialists, ship nurses, pre-hospital nurses,
flight nurses, humanitarian caregivers, and entrepreneurs—and all are emergency nurses.
Their significant contributions have made this book a true atlas of emergency nursing.

As I reflect on how my own emergency nursing career began, quite by accident (or was it
fate?), I will be forever grateful to the U.S. Army Nurse Corps for that fortuitous duty
assignment that changed my life forever. My sincere hope is that this very thoughtful, well-
written book about all things emergency nursing might inspire you to choose or continue
your career in emergency nursing. Enjoy this book—absorb, ponder, deliberate, and commit.
I can think of no greater, more challenging, more satisfying career than emergency nursing
and no finer colleagues than emergency nurses.

–Susan Budassi Sheehy, PhD, RN, FAEN, FAAN

Adjunct Associate Professor
Daniel K. Inouye Graduate School of Nursing
Uniformed Services University of the Health Sciences, Bethesda, Maryland
Past President, Emergency Nurses Association
xx EMERGENCY NURSING

Introduction
A colleague of mine who works as a registered nurse on an inpatient surgical unit made an
interesting observation one evening while we were enjoying dinner together. She pointed
out that when you ask many nurses what they do for a living, they will respond by saying
that they are an “RN” or a “nurse.” She went on to comment that when you ask nurses
who work in the emergency department what they do for a living, they are much more like-
ly to identify themselves as an “emergency nurse.” She asked me why it is that emergency
nurses seem to feel the need to identify the area of nursing they are employed in rather than
simply their career choice as a nurse.

This was not something I had given serious thought to before this conversation, but I began
to pay more careful attention and found there to be some truth to this statement. While
emergency nurses remain an integral part of the nursing field as a whole, they seem to have
a certain sense of pride about working in the emergency department. Emergency nurses fre-
quently identify themselves as a “nurse,” along with their place of employment—the emer-
gency department.

I will have to admit that I fall into this category myself. There has never been a day that I
have regretted entering into nursing as a career. It has met and then far exceeded my expec-
tations. I have had opportunities that I cannot imagine in any other career I might have
chosen. Yet if you ask me what I do for a living, I will most likely reply that I am an
“emergency nurse.” There is a rush of adrenaline that comes with my work in the emer-
gency department. There are many more moments of satisfaction than there are moments
of disappointment, and for that reason, I am proud to be called an “emergency nurse.”

It was this very thought that resonated with me when I was approached about editing a
book about emergency nursing. Why not produce a book about the profession of emergen-
cy nursing? What is it about this particular field of nursing that makes nurses want to iden-
tify themselves as “emergency nurses” instead of simply referring to themselves as a
“nurse”? It is my sincere hope as you pore through the pages that follow, you will better
understand the profession of emergency nursing and what makes it so special.

The book has been divided into three distinct sections. The first section is “Emergency
Nursing as a Profession and Career.” The chapters in this section are designed to introduce
the reader to the profession of emergency nursing. What is it about this segment of the pro-
fession that drives nurses to want to be identified with it? What is the history of emergency
nursing? What career opportunities exist within emergency nursing, and what educational
as well as life experiences will help nurses access those opportunities? What are the profes-
sional responsibilities that accompany being identified as an emergency nurse? What are the
challenges that face the emergency nurse, and how can emergency nurses take care of them-
selves to ensure mental and physical health?
 INTRODUCTION xxi

The second section focuses on the place emergency nurses call “home”—the emergency
department. This section, “The Emergency Nurse in the Hospital Setting,” introduces nurs-
es to the emergency department. What types of emergency departments are there? How
does one emergency department differ from another? When seeking a job in an emergency
department, what should the emergency nurse seek out to ensure compatibility? What are
the different areas in the emergency department, and who are the key players, aside from
emergency nurses, who work there? There is also a chapter on triage in this section, an area
of the emergency department that is unique to the emergency nurse.

The third section of the book, “Emergency Nursing Practice,” is all about the practice of
emergency nursing. What challenges do emergency nurses face when they go to work each
day? How can nurses face those challenges? What are the laws, regulations, and pitfalls
that accompany our practice? One of the challenges emergency nurses face is the fact that
they care for patients across the spectrum of life from all socioeconomic and ethnic back-
grounds. The final chapters of the book will focus on the varied patient populations that
emergency nurses regularly encounter.

For those of you who are already emergency nurses, it is my sincere hope that this book
will give you a deeper understanding of the career path you have chosen and what makes
emergency nursing so unique and such a source of pride. For those of you who are consid-
ering joining the ranks of emergency nurses, I hope the contents of this book will help you
decide if this is the career path for you and how best to maneuver the field to ensure you
meet your personal goals. And for all other readers, I trust the contents of the pages to fol-
low will give you insight into what drives the passion of all of us “emergency nurses.”

–Jeff Solheim, MSN, RN-BC, CEN, CFRN, FAEN (and an “emergency nurse”)
 C h a p t e r
1
Emergency
Nursing Defined
–Renee Semonin Holleran, PhD, FNP-BC, CEN,
CCRN (emeritus), CFRN, CTRN (retired), FAEN

The American Nurses Association (ANA) defines nursing in

the following way: “Nursing is the protection, promotion,
and optimization of health and abilities, prevention of illness
and injury, alleviation of suffering through the diagnosis and
treatment of human response, and advocacy in the care of
individuals, families, communities, and populations” (ANA,
2015).

An emergency is defined as “a serious and unexpected situa-

tion involving an illness or an injury” (Medical Emergency,
2015). Just as there are multiple types of patients who
require specific care, multiple nursing specialties have
evolved to care for these populations. One of these is emer-
gency nursing.

The focus of this chapter is to discuss the history of emer-

gency nursing, the role of the emergency department (ED),
the definition of emergency nursing and its role in emergency
care, and some of the elements that constitute the practice of
emergency nursing.
2 EMERGENCY NURSING

History of Emergency Nursing

Emergency medicine and emergency nursing are modern concepts. Historically, patient care
was generally provided where the illness or injury occurred. There were no hospitals and
certainly no EDs. Some patients were lucky to find a place such as a monastery or church
that may have offered additional care. The early foundations of emergency care came out
of war dating back to the Middle Ages (Sefrin & Weidringer, 1991).

Although emergency care is commonplace in some of the world, many parts of the globe
still do not have any emergency care systems including departments staffed by nurses and
physicians. In 2012, the World Health Assembly adopted Resolution 60.22 titled Health
Systems: Emergency Care Systems, establishing a policy tool for improving emergency care
access and providing emergency care globally (Anderson et al., 2012). The continued lack
of a global emergency system has been brought to an uncomfortable light in global events
such as the Ebola outbreak in Africa that gained national attention in 2014 and natural
disasters such as the Nepal earthquake in 2015.

? In 2012, there were 5,004 emergency departments in the United States (Emergency Medicine
Network, 2012). The total number of emergency departments around the world is unknown.

The Role of Florence Nightingale in Emergency Nursing

Florence Nightingale has long been associated with the origins of emergency nursing; she
took nurses out to the field to provide care to wounded soldiers during the Crimean War in
1854. Nightingale and her colleagues began by identifying the most injured or sickest
requiring care, even on the battlefield. The care she and the nurses she trained demonstrat-
ed the value of rapid management of acute patients (Gebbie & Qureshi, 2006; Shell &
Dunlap, 2008). Nightingale implemented specific interventions that affected patient care,
including reducing overcrowding of patients by keeping beds 3 feet apart, providing venti-
lation in the care area, preventing horses from being stabled in the patient care area, and
flushing latrines daily with peat charcoal (Sheingold & Hahn, 2014).

Florence Nightingale was also responsible for laying the foundation of the nursing profes-
sion and women’s suffrage. She established the Nightingale Training School at the St.
Thomas Hospital in London in 1865. She recognized that nurses played a significant role in
the social care of patients and that this could not be separated from the patient’s healthcare
needs. This is never more evident than in the practice of emergency nurses who experience
this today on a daily basis (MacMillan, 2012). Nightingale was operating within the
 1 EMERGENCY NURSING DEFINED 3

circumstances that were available to her. If getting something done for a patient required
collaboration and/or compromise, she was willing to do this. She worked hard, for exam-
ple, to ensure that patients with mental illness were not only admitted to hospitals but
could stay in the hospital for as long as was needed. Prior to her intervention, patients
with mental health issues were often ignored and denied access to medical care. She dem-
onstrated the role of advocacy, an important part of patient care in emergency nursing
practice (Ayers, 2014).

Florence Nightingale was born in Florence, Italy, on May 12, 1820, and died in the United Kingdom
on August 13, 1910.

Nightingale pressed for the welfare of her nurses. She demanded better working and living
conditions by promoting time off, the use of labor-saving devices, and opportunities for
nurses to advance within their profession. She also monitored nursing mortality and report-
ed these statistics (McDonald, 2013). Safety in the work environment continues to be a sig-
nificant problem in emergency nursing practice today, especially the exposure to and conse-
quences of violence in the ED.

Emergency Nursing in the 20th Century

At the beginning of the 20th century, the Henry Street Settlement in New York City created
the “First Aid Room.” Under the direction of nurse Lillian Wald, impoverished immigrants
received care for minor emergencies such as cuts, local infections, rashes, and some acci-
dents (Snyder, Keeling, & Razionale, 2006). Because the majority of the time nurses were
mostly seeing patients without the presence of a physician, standing orders were developed.
The medical community that existed at the time approved these orders, and nurses who
staffed the First Aid Rooms saw between 10,000 and 23,000 patients annually for 15 years
(Snyder et al., 2006).

As hospitals grew during the 20th century, emergency “rooms,” later recognized as emer-
gency departments, became a place of access for healthcare to many patients. A 1956 sur-
vey on the use of emergency rooms in the Midwest and Atlantic Seaboard found a 400%
increase in the use of the emergency room by patients with many complaints (Coleman &
Errera, 1963). Several reasons given for this increase included patients’ inability to reach
their doctors at night, weekends, or holidays. The survey also found that doctors were
increasingly referring patients to the emergency room for evaluations that could not be
done in an office.

As the patient census in the emergency room increased, so did questions as to whether these
patients needed to be there at all. It was found that patients were defining what qualified as
4 EMERGENCY NURSING

an emergency for themselves. It was noted early that a bad experience in the emergency
room could affect the entire hospital’s reputation (Kennedy, 1957). As a result, hospitals
began to pay specific attention to their emergency rooms and the care provided there.

However, the areas in hospitals dedicated to the emergent care of patients were limited.
Often, the ED was one room and didn’t have a dedicated staff; generally, a nurse was called
down from an inpatient unit or the nursing supervisor cared for the patient.

Emergency nursing and emergency medicine continued to develop into specialties during
the 20th century. The medical and nursing care provided to soldiers during World War II
and the Korean and Vietnam wars demonstrated that rapid and acute care could make a
difference in patient outcomes. It also confirmed the value of collaborative practice among
nurses, physicians, and paramedical personnel. When emergency medicine was recognized
as a specialty in the late 1970s, it quickly became one of the fastest growing medical fields
(Zinc, 2006). Emergency medical services (EMS) also became an integral part of emergency
care.

The role of the nurse in World War II and the Korean and Vietnam wars demonstrated the
importance of nursing in the triage process and the acute care of the ill and injured patient.
During this time, the American Nurses Association (ANA) began to gain more members
and political power to represent the profession and the work of nursing. Societal changes,
including the evolving role of women, laid the foundation for nursing specialties to develop
their own status.

? Fifty-nine thousand American nurses served in the Army Nurse Corps during World War II (U.S.
Army Center of Military History, 2003). More than 700 nurses served in mobile army surgical units
(MASH units), and 4,000 navy nurses served on hospital ships during the Korean War
(Department of Defense, 2010). About 6,250 nurses served in the Vietnam War (United States
Navy and Army, n.d.).

Initially, most nurses who were either assigned to an “emergency” room or were called to
see a patient when one presented had to provide and perform any needed immediate care
and then wait for the physician to arrive. In 1965, the ANA didn’t support this role. Nurs-
es were not to diagnosis and prescribe (Snyder et al., 2006). The specialization of nursing
assisted in identifying the unique functions, responsibilities, and education needed to pro-
vide care in the ED or intensive care unit.

The concern about the lack of enough physicians in the emergency room led to the sugges-
tion of training nurses to perform specific interventions for emergency care. Examples of
some of these interventions included obtaining a pertinent medical history, instituting
 1 EMERGENCY NURSING DEFINED 5

cardiopulmonary resuscitation, stopping hemorrhage, obtaining an EKG, inserting a naso-

gastric tube, performing wound and fracture care including splinting, assisting the physi-
cian in critiquing patient care, and remaining well-informed in new methods of utilizing
emergency communications (Owens, 1970).

Owens (1970) notes:

“Every nurse involved in emergency care should serve a period of training

and indoctrination in what is necessary for emergency care of the patient
at the site, en route to the hospital via emergency transportation, in the
emergency department, operating room, recovery room, intensive care, and
coronary care units.” (p. 48)

The Emergency Nurses Association (ENA)

Two visionary nurses, Anita Dorr and Judith Kelleher, took on the challenge of creating a
way for emergency nursing to be recognized as a specialty. Anita Dorr formed the Emer-
gency Room Nurses Organization. She also put together the first “Resuscitation Cart” that
sits now in the Emergency Nurses Association’s national office in Des Plaines, Illinois.
Judith Kelleher called her association the Emergency Department Nurses Association
(EDNA).

On December 1, 1970, these two nurses combined their organizations into the Emergency
Department Nurses Association (EDNA). Judith Kelleher has also been credited with
remarking that it is an “emergency department, not an emergency room” (Snyder et al.,
2006, p. 202). The roadrunner became the symbol of the emergency room nurse based on
the quick speed at which emergency nurses work. Many of us still proudly wear that pin.

Initially, EDNA and the American College of Emergency Physicians (ACEP) shared the
same offices. As both associations grew, so did issues between the two groups (Patrick,
2010; Schriver, Talmadge, Chuong, & Hedges, 2003). Yet, both associations still continue
to this day to work collaboratively toward ensuring that the quality of care provided in
the ED is evidence-based and the needs of all emergency patients are recognized and met.

The Emergency Department Nurses Association changed its name in 1985 to the Emer-
gency Nurses Association (ENA). The ENA board and membership felt that this better
mirrored where emergency nurses were practicing and the many facets of emergency care.

Today, the ENA reports a membership of over 40,000 members. The ENA has been
responsible for the development and implementation of position statements, educational
products, and several publications. Table 1.1 shows the educational resources that the
ENA provides.
6 EMERGENCY NURSING

Table 1.1 ENA Educational Resources for Emergency Nurses

Resource Description
Trauma Nursing Core Trauma Nursing Core Course (TNCC) is a national and international course that
Course (TNCC) identifies a standardized body of trauma nursing knowledge. The TNCC (Pro-
vider) is a 2-day course designed to provide the learner with cognitive knowl-
edge and psychomotor skills. The purpose of TNCC is to present core-level
knowledge, refine skills, and build a firm foundation in trauma nursing.

Emergency Nursing Emergency Nursing Pediatric Course (ENPC) was developed to improve the
Pediatric Course (ENPC) care of the pediatric patient by increasing the knowledge, skill, and confidence
of the emergency nurse. This 2-day course provides core-level pediatric knowl-
edge and psychomotor skills needed to care for pediatric patients in the emer-
gency care setting.

Course on Advanced CATN is an online advanced course in trauma care for experienced emergency
Trauma Nursing (CATN) nurses. The course involves critical thinking and clinical decision-making
beyond the primary survey. It includes tools to anticipate complications early
in the trauma continuum, resulting in better patient outcomes. CATN courses
offer:
Pathophysiologic concepts
Long-term perspective of trauma care
Evidence-based curriculum
7.3 contact hours, six interactive learning modules
Individual or group study

Geriatric Emergency GENE is a comprehensive eLearning program designed to provide the best evi-
Nursing Education dence-based care for older adults. This extensive course gives nurses the tools
(GENE) to assess special needs in older adults, to recognize atypical presentations,
and to coordinate care that will help improve patient outcomes.

Source: ENA, 2015.

Examples of ENA publications include (ENA, 2015):

■ Journal of Emergency Nursing

■ ENA Connection

■ Core Curriculum for Pediatric Emergency Nursing

■ Emergency Nursing Scope and Standards of Practice

Another random document with
no related content on Scribd:
Miss Parrett herself appeared in the doorway—an accusing and
alarming figure.
“This is a nice way you waste my time!” she exclaimed, with an
angry glance at both. “You and cook gossiping together and idling.
Where are the cloths and the hot water, young man?”
The cook, grumbling audibly and insolently, went back to the dresser,
and Miss Parrett, with folded arms, waited dramatically in the kitchen
till Wynyard was provided for. He then walked off with a brief “Thank
you” to his fellow-culprit. As he passed along the flagged passage he
caught Miss Parrett’s shrill voice saying—
“Now, I’ll not have you flirting with that young man, so I warn you! I’ll
have no carryings-on in my house.”
Then a door was slammed with thunderous violence, and there was
silence.
No, by Jove, he could not stand it, he said to himself as he set down
his bucket, and wrung out a cloth; like the cook, he, too, would
depart, and in his next situation stipulate for no women. Of course
Leila would be disappointed, and he was sorry; but Leila would never
ask him to put up with this! He would give a week’s notice and
advertise; he had enough money to keep him going for a while, and
his certificate.
Presently he set to work on the dining-room, where there were three
old casemented, mullioned windows; to clean these he stood on the
lawn, and had begun his job when Miss Susan entered, smiling and
radiating good humour.
“I dare say you don’t know much about this sort of work,” she began
apologetically, “and I’ll just show you! You have to use lots of clean
water, and stand outside on the lawn—no fear of breaking your
neck.” Then in another tone she added, “I’ll see you are not asked to
do this again; at present we are rather short-handed, but by and by
everything will go smoothly.” She was about to add something more,
when her sister put her head in at the door, and called out—
“Now, do come away, Susan, and don’t stand gossiping with the
young man, and idling him at his work. He has wasted half an hour
with the cook already!”
Wynyard, as he rubbed away at the panes, whistled gaily whilst his
mind dwelt on many matters, amongst others of how strange that he
should be down in this queer, God-forsaken village, living in a
labourer’s cottage, and employed in cleaning windows! Well, he had
Miss Susan’s word for it that he would not be asked to do it again;
she was a good sort, with a nice, cheery face, and such a pair of
twinkling blue eyes. Then he thought of the tragic cook, also sent by
Leila, and he laughed aloud. The house wanted a lot of servants,
and as far as he could gather the staff was short-handed; probably
Miss Aurea would see to all this, since she managed every one in
Ottinge, did as she liked, and was the prettiest girl within ten
parishes!
Wynyard was a handy man, and got through his work rapidly and
well. He fetched many cans of water, and presently moved on to the
drawing-room—another low room with heavily beamed ceiling and a
polished oak floor. The apartment was without carpet or curtains,
and scantily furnished with various old chairs, settees and cabinets,
ranged against the wall. He was sitting outside on the sill, whistling
under his breath, polishing his last casement, when he heard,
through the half-open door, a clear young voice talking with
animation, and a girl came into the room laughing—followed by an
Aberdeen terrier on a leash. As she advanced, he noticed that she
had wild rose colouring, wavy dark hair, merry dark eyes, and an
expression of radiant vitality. Tom was right! Here, no doubt, was
Miss Aurea, the prettiest girl in ten parishes!
As Wynyard looked again at this arresting vision something strange
seemed to stir in his heart and come to life. First impressions have a
value distinct from the settled judgment of long experience.
“What a floor, Susie!” exclaimed the young lady. “Really, we must get
Aunt Bella to give a dance;” and as she spoke she began to hum the
“Merry Widow Waltz,” and to execute some remarkably neat steps,
accompanied by the terrier, who struggled round in her wake,
barking indignantly.
“Mackenzie, you are an odious partner!” addressing the animal; then
to her aunt, “I’ve brought him on the chain, and he has me on the
chain; he is so strong! We have accosted and insulted every single
village dog, and frightened Mrs. Watkins’ cats into hysterics!
However, he can’t get loose and murder poor gentlemanly Joss! Oh,
we little knew what we were doing when we accepted Mac as a
darling puppy!”
“I must confess that I never care for these aggressive, stiff-necked
Aberdeens, and I don’t pretend to like Mac. To tell you the honest
truth, I’m mortally afraid of him!”
“But he must be exercised, Susan. And now we must exercise
ourselves, and begin on this room. I’ve sent over the curtains, and
they are ready to go up.”
Suddenly she noticed the stranger, who was polishing a distant
window. “Why, I thought it was Hogben!” she muttered. “Who is it,
Susie?” and she looked over at Wynyard with an air of puzzled
interest.
“The new chauffeur, my dear,” was the triumphant response. “He
only came yesterday; his name is Owen.”
“Oh!” exclaimed the girl, turning her back to the window and
speaking in a low voice. “And didn’t he object?”
“No; but I fancy he doesn’t like it. He seems a nice civil young fellow.
Lady Kesters found him for us.”
“Did she? I sincerely hope he is a better find than the cook. What a
fury! Even Aunt Bella is afraid of her!”
“She has a splendid character from her late mistress.”
“I dare say, in order to pass her on at any price. She’s a first-rate
cook, but a regular demon.”
“My dear, they all have tempers—it’s the fire, poor things. Now,
about the chauffeur——”
At this moment the object of her conversation threw up the sash and
stepped into the room—a fine figure in his clean blue shirt, turned up
to the elbows, well-cut breeches, and neat leather leggings.
“I’ve finished this room, miss,” he said, addressing himself to Miss
Susan. “What am I to do next?” and his eyes rested upon her with
respectful inquiry.
“No more windows to-day, thank you, Owen. I expect it is nearly your
dinner-hour.”
“Shall you require the car this afternoon, miss?”
“No; but it will certainly be wanted to-morrow,—eh, Aurea?”
“Then I’d better take her out and give her a turn;” and with this
remark he picked up his bucket and rags, and walked out of the
room.
During this brief conversation, Aurea stood by listening with all her
ears, and making mental notes. Her aunt’s new chauffeur, with his
clean, tanned, high-bred face, spoke like an educated man.
“My dear Susie,” she inquired, “where did Lady Kesters get hold of
such a superior person?”
“I’m sure I can’t tell you. She said she had known his family all her
life, and that they were most respectable people. Chauffeurs are
supposed to be smart, and well-groomed, eh?”
Yes, but there was more than this about the late window-cleaner—
something in his gait, carriage, and voice, and, unless she was
greatly mistaken, the new employé was a gentleman; but with
unusual prudence Aurea contrived to keep her suspicion to herself.
Aloud she said—
“Well, now, let us see about the carpet! This room ought to be settled
at once—pictures up, and curtains; there’s no place to ask visitors
into, and you’ve been here six months. You are lazy, Miss Susan
Parrett—this is sleepy hollow.”
“Oh, my dear child, you know perfectly well it’s your Aunt Bella; and
she won’t make up her mind. What’s done one day is taken down
another. What is that awful row?”
“It’s Mackenzie and Joss,” cried Aurea, dashing towards the door.
Mackenzie, at large and unnoticed, had stealthily followed the
chauffeur out of the room, and stolen a march upon his deadly
enemy—Miss Parrett’s impudent and interloping mongrel. The result
of this dramatic meeting was a scene in the hall, where Miss Parrett,
mounted on a chair, looked on, uttering breathless shrieks of “Aurea!
Aurea! it’s all your fault!” whilst round and round, and to and fro,
raged the infuriated animals, snarling and growling ferociously, their
teeth viciously fastened in each other’s flesh.
Mackenzie, the more experienced, able-bodied, and malevolent of
the two, had Joss by the throat—Joss, for his part, was steadily
chewing through Mackenzie’s fore-leg.
Here Wynyard came to the rescue, and, though severely bitten,
succeeded after some difficulty in separating the combatants; he and
Miss Aurea somehow managed it between them, but he had borne
the brunt of the fray, the forefront of the battle.
A good deal of personal intimacy is involved in such encounters, and
by the time the panting Mackenzie was hauled away by the collar,
and the furious Joss had been incarcerated in the dining-room, the
new chauffeur and Miss Morven were no longer strangers.
 CHAPTER X
AS HANDY MAN

The chauffeur was informed that there were no orders for the car the
following morning, as “Miss Parrett was suffering from neuralgia in
her face,” and also—though this was not mentioned in the bulletin—
a sharp pain in her temper.
Aurea, an early visitor, radiating gaiety, was on this occasion
unaccompanied by Mackenzie. Mackenzie, aged six years, was the
village tyrant and dictator. He also had been accustomed to consider
himself a dog of two houses—the Rectory and the Red Cottage; and
when the Red Cottage had moved to the Manor, and installed an
animal of low degree as its pet, he was naturally filled with wrath and
resentment, and on two opportunities the intruder had narrowly
escaped with many deep bites, and his life!
Aurea found her Aunt Bella trotting about the premises and
passages, with the knitted hood over her head, and key-basket in
hand.
“Not going out to-day!” she exclaimed; “but it’s lovely, Aunt Bella. The
air is so deliciously soft—it would do you no end of good.”
“My dear Aurea,” she piped, “I know you don’t allow any one in
Ottinge to call their soul their own, and I must ask you to leave me
my body, and to be the best judge of my ailments—and state of
health.”
“Oh, I beg your pardon, Aunt Bella; I meant no harm. Well, then, if
you are not going to use the car yourself, perhaps Susan and I could
take it over to Westmere? The Woolcocks have a large house-party,
and Joey and her husband are there.”
Miss Parrett closed her eyes tightly—a sure hoisting of the storm
cone—and screwed up her little old face till it resembled an over-ripe
cream cheese.
“Really, Aurea! I don’t know what the world is coming to! How dare
you propose such a thing! Take out my car for the first time without
me! But, of course, I know I’m only a cipher in my own house!”—an
almost hourly complaint.
“But do think of the chauffeur, Aunt Bella; is he to have nothing to
do?” Here this crafty girl touched a sensitive nerve—a responsive
key.
“Plenty for him to do; there’s enough work in the house for twenty
chauffeurs: unpacking the book boxes and china—never opened
since your grandfather’s death—staining the floors, and putting up
the curtains, and laying carpets. If you and Susan are going to settle
the drawing-room at last, he may help you. I can’t spare Jones or
Hogben from the garden.”
“Very well, we must have some one to lift the heavy things, and
stand on ladders. Where is he?”
“Outside in the hall, awaiting my orders,” replied Miss Parrett, with
magnificent dignity, folding her hands over what had once been a
neat waist, but now measured thirty inches.
Yes, the chauffeur was in the hall, cap in hand, attended by the
grateful Joss, and had overheard the foregoing conversation.
Miss Parrett came forth as she concluded her speech, and issued
her commands.
“Owen, you are to help my sister and Miss Morven in settling the
drawing-room. Be careful how you handle things, and don’t break
anything; and you may have your dinner here for to-day, with the
other servants.”
“Very good, ma’am,” he assented.
But with respect to dinner with the servants, it was really very bad.
He would be compelled to fence with the London cook, and keep her
and her civil proposals at arm’s length—no easy job!
From ten o’clock till half-past one, Wynyard spent an agreeable and
busy time in the service of Miss Susan and her niece. His boast to
his sister that he was “clever with his hands” was fully justified. He
hung the chintz and white curtains with the skill of an upholsterer, he
laid the dark blue felt on the floor, stretched it and nailed it neatly in
its place, whilst Aurea stood by, and gave directions, and sometimes
—such was her zeal—went down on her knees beside him, and
pulled and dragged too, exertions which enabled her associate to
realise the perfect curve of cheek and neck, and the faint perfume of
her glorious hair!
And all this time industrious Miss Susan sewed on rings, fitted loose
chintz covers, and talked incessantly. She did not appear to find the
presence of the chauffeur the slightest restraint—indeed, he was so
quiet and kept his personality so steadily in the background, that as
aunt and niece chatted and conferred, measured and altered, they
seemed to have entirely forgotten his existence, and as the old
drawing-room was full of nooks, angles, and deep windows, he was
not only out of mind, but also out of sight. Meanwhile, he enjoyed the
rôle of audience, especially in listening to Miss Aurea! What a gay,
light-hearted girl! And in her playful arguments with her aunt, he
realised the delightful camaraderie that existed between them. Her
chaff was so amusing that, although he was not included in the
conversation, he often felt inclined to echo Miss Susan’s appreciative
laugh. Never had he come across any one who had attracted him so
much; the more he saw of Miss Morven the more he admired her!
Possibly this was because for the last twelve months he had not
been brought in contact with a happy, high-spirited English girl—or
was it because in this out-of-the-world village he had met his fate?
As Wynyard hung curtains, and put in screws, he stole swift glances
at Miss Susan’s busy helper, noticed her slim elegance, her
infectious smile, and lovely face. It was a ridiculous, but absolutely
true fact, that to see a really beautiful, charming, and unaffected girl,
one must come to Ottinge-in-the-Marsh!
Meanwhile, as he worked in the background, he gathered up many
crumbs of conversation, and scraps of family and local news. He
learned that Mr. Morven’s great work on The Mithraic Heresy and Its
Oriental Origin was nearly complete, that the Manor cook had given
notice, and that no one had rented the fishing.
“The Woolcocks have a houseful at Westmere,” so said Miss Susan,
“and their staff of servants had recently enjoyed a sensational
turning out. Joey Waring and her husband are there, just back from
their winter trip.”
“And how is Joe?” inquired Aurea.
“Her hair is twice as fluffy, and she is louder, noisier, and talks ten
times more than ever!”
“Now, Susan, you know that is impossible!”
“Yes; Kathleen declares that you can hear her laugh as you pass the
park gates.”
“What! a whole mile away! She must have mistaken one of the
peacocks for Joey, and however loud she laughs and talks, she
never says an unkind word of any one.”
“No, a good, kind little soul! but I wonder Captain Waring can stand
her, and her chatter does not drive him crazy.”
“On the contrary, he adores her, and is enormously proud of her flow
of animation and conversation. You see, he is so silent himself, Joey
is his antithesis; and Joey is worshipped at home, for in a family of
large, heavy, silent people, a little gabbling creature is appreciated.
Tell me about Kathleen.”
“Oh, Kathleen is, as usual, very busy and cheery; she has three new
boarders—hungry and quarrelsome.”
“And he?”
“Just as usual too, dear. You know he never can be better.”
“But he may grow worse!”
“Oh, don’t speak of such a thing! Think of Kathleen.”
“Yes; and I think Kathleen is a saint—so brave and unselfish. Now,
where shall we put the old Palairet mirrors?”
“You had better consult your Aunt Bella.”
“My dear, good Susan!” (This was the style in which she addressed
her relative.) “Don’t you know your own sister by this time? She has
been here nearly seven months, and you are not half settled yet—
only bedrooms and dining-room—and I have undertaken to help you
finish off in three days.”
“Yes, but that’s nonsense, though I must say you’ve worked miracles
this morning—curtains, covers, carpet; but there was no question of
where they had to go. As to pictures, mirrors, and cabinets, it will
take your aunt a twelvemonth to decide how to place them.”
“I shall decide, and place them to-day,” rejoined the girl, with calm
decision; “if I ask Aunt Bella, they will be tried on every wall, till our
backs are broken, and then taken down after all. The round glass
between the windows,”—looking about and speaking with authority
—“the other over the mantelpiece, the Chinese cabinet in that niche
—they are just made for one another—the Charles the First black
bureau from the schoolroom just here, and the screen from her
bedroom by the door.”
“My dear child, you”—and she broke into a laugh—“you wouldn’t
dare!”
“Would I not? Just wait and see. The room is charming, and when it’s
finished Auntie B. will be enchanted! You may leave her to me. Oh,”
in another tone to Wynyard, who had come forward in search of
some wire, “you have worked well. It must be your dinner-hour. We
shall be ready to start again at half-past two o’clock, and then the
parlour-maid will help you with the furniture.”
“Very well, miss,” he answered.
As Aurea walked off, followed by Miss Susan, Wynyard the imposter
assured himself that Miss Morven was quicker witted than her aunts.
He had noticed her expression of keen attention as he discussed a
matter of a curtain pole with her relative, and it was quite possible
that she already had an inkling of the truth! He must be careful and
wary not to give himself away or utter a word beyond “Yes, miss,”
and “No, miss.” He was already attending closely to the speech of
Tom Hogben, and had marked the scantiness and laziness of his
vocabulary; how he never said more than he could help, and used
the words, “Sure-ly,” and “I dunno,” and “ye see,” and “’ee” for “he,”
and “I be” for “I am,” and resolved to imitate him.
The meal in the servants’ hall proved an even more trying ordeal
than he anticipated, and was altogether so disagreeable to the new
chauffeur that, sooner than face it again, he determined to fast.
The London cook (Miss Hicks) and four maids were present, also the
boot-boy—a clumsy yokel, who was in terrified attendance. Owen
sat on Miss Hicks’ right hand, and received all her attention, the best
helpings, and daintiest morsels of a solid and satisfying meal.
She would scarcely suffer the other servants to address him, though
the rosy-cheeked parlour-maid made bold and even desperate
attempts. She plied him with questions, compliments, and
information. For his part, he proved a disappointing guest, and did
not afford Miss Hicks much satisfaction; she came to the conclusion
that in spite of his fine figure and good looks the chauffeur was a dull
sort of chap, and terribly backward at taking a hint. When she
nudged him with her elbow, and pressed his foot under the table,
there was no response—in fact, he moved a bit away! However, she
laid the flattering unction to her soul that the poor fellow was shy. He
was duly favoured with the cook’s candid opinion of the place and
their employers, namely, that Miss P. was an old terror, was a
shocking one for running after lords and ladies, and talking grand,
yet that mean and sneaking she would frighten you! She and Miss
Norris, housekeeper at the Rectory, were cuts, only for the Rector;
anyway, Norris never came to the Manor. Miss Susan was a lady, but
a giddy old thing, so fond of gadding and amusement, and laws!
what a one to talk! As for Miss Aurea——
No, he could not sit by and hear Miss Aurea dissected, and with an
excuse that he wanted to have a pipe before he went back to his job,
the chauffeur pushed away his unfinished cheese, and with a civil
farewell took his departure.
The afternoon was a busy one: the mirrors were put up, pictures
were hung, but with many incursions and interruptions from Miss
Parrett. Joss, the dog, was also in and out, and seemed inclined to
attach himself to Wynyard.
Miss Parrett, still hooded, sat upright in an arm-chair, offering
irritating criticisms, and quarrelling vigorously as to the position of
pictures and articles of furniture; the old lady was altogether
extremely troublesome and argumentative, and gave double work.
Thoroughly alive to the fact that her niece had good taste, she was
jealous of her activities, and yet wished to see the old rooms
arranged to the best advantage—as the result would redound to her
personal credit.
It was an immense relief to the three harassed workers when the
parlour-maid entered and announced—
“If you please, Miss Parrett, Lady Mary Cooper has called, and I’ve
shown her into the study.”
“You mean the library,” corrected her mistress. “Say I’m coming;” and
she trotted over to a glass, removed her hood, and called upon
Aurea to arrange her cap.
“Time Lady Mary did call!” she grumbled. “We are here seven
months.”
“She has been abroad,” said Susan; “and, anyway, she’s not much
of a visitor.”
“Well, she is our own cousin, at any rate.”
“Our cousin—Lady Mary!” repeated Miss Susan. “I do declare, Bella,
you have a craze for cousins. Why, we scarcely know the woman!”
“Now, Susan, don’t argue! She is our relative; her great-great-aunt
married a Davenant, and I suppose you will allow that they are our
kin? I have no time to explain now;” and she pattered off,
abandoning the workers to their own devices.
“Your Aunt Bella is so funny about relations! People I’ve never heard
of she will say are our own cousins.”
“Yes, to the tenth generation,” agreed Aurea, “if they are well born.
Aunt Bella has pedigree on the brain—for myself, I think it a bore.”
It was strange that Miss Parrett, who, on her mother’s side, was the
granddaughter of a rough Hoogly pilot, should be as haughty and
exclusive as if she were an Austrian princess. In the neighbourhood
it had become a well-established joke that, if any one of importance
and old family was mentioned before Miss Parrett, she was almost
sure to announce—
“Oh, I don’t know much about them personally, but they are our
cousins!”
By six o’clock the task of arranging the drawing-room was
completed. Wynyard had been assisted by the rosy-cheeked maid in
bringing tables, cabinets, and china from other rooms, and they
really had, as Miss Susan declared, “worked like blacks.”
“It is a dear old room!” said Aurea, surveying the apartment with
unconcealed complacency. “When the bowls are filled with flowers,
and we have a bridge table, and a jigsaw puzzle, we shall be perfect
—old-fashioned, and in the fashion.”
“Glad you think so!” said a little bleating voice in the doorway. “Lady
Mary asked for you, Susan, and I told her you were out, or she’d
have wanted to come poking in here. So”—looking about—“you’ve
brought the black cabinet out of the schoolroom! Who gave you
leave to do that? And”—she threw out a quivering forefinger—“the
blue china bowls from the spare room, and my screen! You take too
much upon yourself, Aurea Morven! You should have consulted me.
I am tired of telling you that I will not be a cipher in my own house!”
Aurea coloured vividly. Did her aunt forget that the chauffeur was
present? Really, Aunt Bella was too bad. She glanced at the young
man, who was standing on the steps straightening a picture;
apparently he was absorbed in his task, and to all appearances had
not heard the recent conversation.
“Oh, I’m so sorry you don’t like the room, Aunt Bella!” said Aurea,
seating herself in a high old chair, crossing her neat feet, and folding
her hands.
“Sorry!”—and Miss Parrett sniffed—“that’s what you always say!”
“Now, my dear, please don’t be so cross,” she replied, unabashed;
“you know, in your heart, you are delighted, and as proud of this
drawing-room as a peacock with two tails.”
“Aurea!” shrieked her aunt.
“You have been here seven months, and you’ve not a single place in
which to receive visitors. Look, now, at Lady Mary—you had her in
the musty old study—and why?”—waving an interrogative hand
—“simply because for months you could not make up your mind
about the arrangement of this room. All the county have called—the
first calls—and carried off the first impressions. None of your lovely
old things were to be seen, but waiting to be settled.”
“Aurea, I will not suffer——”
“Please do let me finish, dear. Before I left, you may remember how
you and I talked it all over—cabinets, china, sofas—and settled
exactly where everything was to fit. I come back at the end of a
month and I find nothing done; so I’ve made up my mind to work
here for several days. I’ve asked the padré to spare me. This room is
finished, and looks extremely nice; the next I take in hand will be the
den! Now, as it’s after six o’clock, I’m afraid I must be off;” and she
arose, stooped down, and kissed her aunt on the forehead, adding—
“Of course I know, dear, that you are immensely obliged to me, and
so you need not say anything. Good-bye—good-bye, Susie,” waving
her hand, and she was gone, leaving Miss Parrett in the middle of
the room temporarily speechless.
“Well—up—on my word!” and she took a long breath.
“After all, Bella, Aurea has made the room perfectly charming,” said
Miss Susan, with unusual courage. “It’s the prettiest in the whole
neighbourhood; the old things never were half seen before. She
sewed the curtains herself, and, until to-day, we’ve never had any
decent place to ask visitors to sit down in.”
“Oh yes, it’s all very well, but if she hadn’t my nice old things to work
with, she couldn’t have made up such a room. Yes, I’m always just—
every one says my sense of justice is my strong point—and I admit
that she helped; what I object to is Aurea’s way—her way,” she
repeated, “of just doing exactly whatever she chooses, and smiling in
your face. She leads the whole of Ottinge by the nose, from the
parson, her father, down to Crazy Billy.” And Wynyard, who was
listening to this declaration, told himself that he was not surprised.
Miss Parrett was not particularly attached to her niece, although she
was by no means indifferent to her fascinating personality, and a
sunny face that brought light and gaiety into the house; but this
wizened old woman of seventy-four grudged the girl her youth, and
was animated by the natural antagonism of one who has lived,
towards one who has life before her!
 CHAPTER XI
THE TRIAL TRIP

At last, with considerable pomp and circumstance, after a whole

week of procrastination, Miss Parrett ventured to inaugurate her
motor.
She appeared in a long fur cloak and gigantic sable stole—a
shapeless bundle, resembling a well-to-do bear, with a cross human
face. Susan, who, after all, was but fifty, looked unusually trim and
young in a neat tailor-made, and becoming toque, whilst Aurea—
who had been permitted to share in the triumph—was so pretty
herself, that one scarcely noticed what she wore, merely that she
exercised marvellous dexterity in the matter of introducing a large
black hat into the interior of the car.
The household were collected for this supreme event: the cook,
scowling and scornful, three maids, Hogben, Jones the head
gardener, and the boot-boy, all assembled to witness the start—even
Joss was in attendance. The motor (in truth a whited sepulchre) had
been recently done up, and with its good-looking driver in smart
leather coat and cap, presented an imposing appearance as it sped
down the drive.
Miss Parrett closed her eyes, and when it swung out of the gate with
a slight lurch, she gave a loud scream, but as it glided up the street,
and she noticed that all eyes were on her car (there was Mrs.
Ramsay at her door, and the doctor’s wife too), she became
comparatively composed. At the gate of the Rectory the Rector
awaited the great sight, and waved a valedictory stick; then they
sped along easily, and, being now out of the village, Wynyard put on
the second speed, but was instantly arrested by Miss Parrett’s
protesting cries.
“Tell him to stop!” she called to her sister. “Supposing we met
something. There!” as they passed the local carrier’s cart within
three yards.
“Owen, you are not to go so fast!” commanded Susan. “Miss Parrett
is nervous.”
He obediently slowed down to eight miles an hour, and as the old
machine joggled along, bumping and shaking, the window-glasses
rattling, the chauffeur was conscious of a feeling of angry contempt,
instead of the usual partiality which a driver reserves for his own car.
He had heard that a driver should be in tune with his machine, but
how could any sane man be in sympathy with this bone-shaker? He
was confident that after a long journey, or any extra strain, the old
thing would collapse and fall to pieces.
After many directions, and not one poor little adventure, they entered
a long avenue leading to an imposing Tudor house with picturesque
chimney-stacks, situated in a great park. This was once the family
seat of the Davenants—cousins of the Wynyards; and as she saw
the end of her journey, Miss Parrett’s courage mounted. When the
car was crawling, or, better still, at a full stop, she was extremely
fond of motoring and not the least nervous.
As the visitors approached the hall door, they overtook a large and
lively house-party, who were returning from the golf links to tea. They
included Mr. Woolcock—a burly figure in knickerbockers, and brilliant
stockings,—his vivacious married daughter, Mrs. Wade Waring,
commonly known as “Joey,” her husband, and half a dozen guests—
altogether a smart and cheerful crowd.
After the first noisy greetings had subsided, Mrs. Waring seized upon
Aurea; she, to use her own expression, “adored the girl.” Aurea
Morven was so pretty to look at, so gay, and so natural, it was a sin
to have her buried in Ottinge; and she secretly designed her for her
future sister-in-law. Aurea was just the wife for Bertie. He was heavy,
dull, and stodgy—a complete contrast to herself, with her animated
face, lively gestures, wiry figure, and ceaseless flow of chatter.
As, arm in arm, she was conducting her friend indoors, she halted for
a moment to look back.
“So that’s the wonderful new motor!” she exclaimed dramatically. “I
say, where did you find such a tophole chauffeur? Why,” she
screamed, “I know him! It’s Owen; he was a saloon steward on the
Anaconda!” and Wynyard, seeing that he was recognised, made a
virtue of necessity, and touched his cap.
“Why, Owen,” hastily descending the steps as she spoke, “fancy you
on dry land! So you’ve given up the sea, and taken to a new trade.
How do you like it?”
“It’s all right, thank you, ma’am,” he answered, with an impassive
face.
“I hope you got the beautiful white-covered umbrella I left for you?”
“Yes, thank you, ma’am.”
“I was afraid the stewardess might bag it! I thought it would be useful
to you in Buenos Ayres, when you were walking in the Calle Florida
with your best girl!” and she surveyed him with twinkling eyes.
“Come, come, Joey!” expostulated her father; “you are blocking up
the gangway, and we all want our tea. Let the man take his car
round.”
“But only think, dad, he was my pet steward coming home,” declared
his lively daughter; “on rough days he brought me chicken broth on
deck, and was so sympathetic—just a ministering angel! Toby will tell
you what a treasure he was, too. He always had a match on him,
always knew the time, and the run, and was the best hand to tuck a
rug round me I ever knew!”
Long before the conclusion of this superb eulogy, (delivered in a
high-pitched voice from the steps), its subject had found a refuge in
the yard.
“Isn’t it extraordinary how one comes across people?” continued
Joey, as she led Aurea indoors. “Fancy your chauffeur being one of
the stewards on the Anaconda!”
“What’s that you say about my chauffeur?” demanded Miss Parrett,
with arrogant solemnity, who had been a disapproving witness of the
recent scene. (She considered Joey Waring a shockingly fast, vulgar
little person, who absorbed far too much of the general conversation
and attention; but as she was the wife of a wealthy man, and the
sister of a notable parti, she dissembled her dislike, or believed she
did. But Joey was aware that the eldest “Polly” considered her a
terribly inferior, frivolous sort of person.)
“I’m only saying how odd it is to find a steward turned into a
chauffeur! I do hope he is experienced, dear Miss Parrett, and that
he won’t bring you or the car to grief. I call him quite dangerously
good-looking, don’t you?”
To this preposterous question Miss Parrett made no reply, merely
squeezed up her eyes, tossed her head, and as she followed Mrs.
Woolcock into the drawing-room her feathers were still quivering.
After tea Mrs. Waring carried Aurea off to her room to enjoy a good
gossip, and to exhibit some of the treasures she had collected during
her recent trip. Joey and her husband were enterprising travellers;
he, a big, silent man—the opposite of his lively little wife—was also a
mighty sportsman.
“Now, let me hear what you have been doing with yourself, Aurea,”
said the lady, after a long and animated description of her own
experiences in the West Indies and Buenos Ayres. “You have been
up in town, I know. Do tell me all about your love-affairs—I know they
are legion. Do confide in little Joey!”
“My love-affairs!” and the girl laughed. “I have none; and if I had,
Joey, you are about the worst confidante I could find. All particulars
would be given out no later than at dinner to-night, and you’d put my
most heart-breaking experience in such a light, that every one would
be shrieking with laughter.”
“Well, anyway, you are heart-whole so far, eh?”
“Yes; I think I may admit that.”
“And so your Aunt Bella has set up a motor; what possessed her?”
And she stared into the girl’s face, with a pair of knowing, light grey
eyes. “She’s as nervous as a cat!”
“Aunt Bella was possessed by the spirit of contradiction. And, talking
of the car, do tell me some more about the chauffeur.”
“Or the waiter that was,” lighting another cigarette. “He was awfully
quick and civil; every one liked Owen.”
“Did it strike you, Joey, that he was something above his class—er—
in fact, a gentleman?” And as Aurea asked the question she
coloured faintly.
“No, my dear,” rejoined her friend, with decision. “I have not a scrap
of imagination, or an ounce of romance in my composition. Such an
idea never dawned on me. You see, Toby and I go about the world
so much; although we have two big houses, we almost live in hotels,
and I am accustomed to being served by men with nice voices and
agreeable manners, who speak several foreign languages. So sorry
to dispel your illusions, but Owen waited to the manner born. He may
have been trained in some big house, and been a gentleman’s
gentleman. I fancy he is a roving character. I think some one said he
had been on a ranch up-country.”
Aurea looked out of the window, and was silent. Joey knew the
world, and Joey, for all her free-and-easy ways and her noisy
manners, was au fond a sensible, practical, little person.
“I dare say you are right, Joey,” she remarked at last.
“Why, of course I am! I grant you that the man is rather an unusual
type of chauffeur, to come down to a dull situation in a dull little
village; but, for goodness’ sake, don’t run away with the idea that he
is some swell in disguise, for he is not; he is just ‘off the cab rank’—
no more and no less. I admit his good looks, but that’s nothing. One
of the handsomest young men I ever saw was a London carriage
groom. I give you my word, his eyelashes were half an inch long! In
these days, too, there are such hideous scandals about women and
their smart chauffeurs, that one cannot be too reserved or too
careful.”
“Joey!” cried Aurea, turning on her with a crimson face.